Peptic ulcers: diagnosis and tests

Your doctor may suspect a peptic ulcer based on your symptoms and whether you have any risk factors. The main causes of peptic ulcers are infection with a type of bacteria called Helicobacter pylori (H. pylori) and regular use of nonsteroidal anti-inflammatory drugs (NSAIDs), which include ibuprofen and aspirin.

To help make a diagnosis, your doctor will want to do a physical examination and organise tests to look for signs of peptic ulcers or any complications that may have developed.

Your general practitioner (GP) may refer you to a gastroenterologist (specialist in conditions affecting the digestive system) for tests and treatment. The tests your doctor recommends will depend on your age and the nature of your symptoms. Some tests are more invasive than others, but may give more information.

Gastroscopy

A gastroscopy can be done to confirm a diagnosis of peptic ulcer. However, gastroscopy is often only recommended for people aged 55 years and older and those with worrisome symptoms or symptoms that may indicate complications.

A gastroscopy (also called upper gastrointestinal endoscopy) involves the use of a thin, flexible lighted tube with a camera, called an endoscope. It is usually done under light sedation because the endoscope needs to be passed through your mouth and down the throat to reach your stomach and duodenum.

During the procedure, your doctor will view and take images of the lining of the stomach and duodenum. If they find an ulcer, they may take some tissue samples (biopsies). The biopsy samples can be tested for the presence of Helicobacter pylori (H. pylori) - the cause of many peptic ulcers.

Non-invasive Helicobacter pylori tests

There are also several non-invasive tests that can detect an infection with H. pylori. Non-invasive Helicobacter pylori tests are often recommended for people younger than 55 who have typical peptic ulcer symptoms.

If the tests confirm you have H. pylori infection, your doctor will prescribe treatment to eradicate the infection. If your symptoms don’t improve with treatment, a gastroscopy may then be recommended.

H. pylori breath test

The H. pylori breath test (also called the urea breath test) is an accurate test that can determine whether you have H. pylori in your stomach or duodenum. The breath test can also be done as a follow-up test to check whether H. pylori infection has been successfully treated.

The urea breath test uses the fact that H. pylori bacteria make an enzyme called urease. This enzyme (which breaks down a substance called urea) is not usually found in the stomach or duodenum - it is only present in people with an H. pylori infection. (The urease is what enables H. pylori to survive in the acidic environment of the stomach and duodenum.)

What happens during a urea breath test?

The test involves firstly swallowing a special solution or capsule containing radioactively labelled (14C) urea. If there is an H. pylori infection, the urease from the bacteria will break down the urea, and the breakdown products (one of which is carbon dioxide) will also be radioactively labelled.

The second part of the test involves exhaling into a special bag, which is sealed and sent to a laboratory to be tested for radioactively labelled carbon dioxide. ‘Labelled’ carbon dioxide will only be present if there is an H. pylori infection.

The amount of radioactivity you are exposed to during a breath test is very low - about the same as the amount we are exposed to naturally in one day of everyday life. However, there is a non-radioactive (13C) breath test that can be used in women of childbearing age and in children.

Other H. pylori tests

H. pylori can also be detected in a stool sample (poo sample). Your doctor will give you a special container to collect a sample at home, which is then sent to a laboratory. The H. pylori stool antigen test can be done to diagnose infection and to confirm successful treatment of the infection.

A blood test can also be done for H. pylori. The test detects antibodies to the bacteria, which may indicate a current or past infection with H. pylori. The blood test is generally less accurate than the breath and stool tests.

Other tests

Your doctor may recommend blood tests to check for possible complications of peptic ulcers, such as bleeding. A full blood count (FBC) can be used to test for anaemia, which is a sign of possible blood loss.

Kidney function blood tests may also be recommended if you have a peptic ulcer that is caused by NSAID use. That’s because frequent, long-term use of NSAIDs can damage the kidneys as well as cause peptic ulcers.

Previously, special X-rays of the stomach and duodenum were used to diagnose peptic ulcers. These tests involve drinking a chalky liquid containing barium to highlight the upper digestive tract so that it showed up on the X-ray. These days, barium X-rays are not routinely recommended.

References

1. BMJ Best Practice. Peptic ulcer disease (updated Jan 2018; reviewed Sep 2018). https://bestpractice.bmj.com/topics/en-gb/80 (accessed Oct 2018).
2. Mitchell H, Katerlaris P. Epidemiology, clinical impacts and current clinical management of Helicobacter pylori infection. Med J Aust 2016; 204 (10): 376-380. || doi: 10.5694/mja16.00104. https://www.mja.com.au/journal/2016/204/10/epidemiology-clinical-impacts-and-current-clinical-management-helicobacter (accessed Oct 2018).
3. Yaxley J, Chakravaerty B. Helicobacter pylori eradication - an update on the latest therapies. AFP 2014;43(5):301-5. https://www.racgp.org.au/afp/2014/may/helicobacter-pylori-eradication/ (accessed Oct 2018).
4. Royal College of Pathologists Australia. Urea breath test (updated 3 Jun 2015). https://www.rcpa.edu.au/Library/Practising-Pathology/RCPA-Manual/Items/Pathology-Tests/U/Urea-breath-test (accessed Oct 2018).
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